Schistosomal portal hypertension

Laparoscopic Treatment of Presinusoidal Schistosomal Portal Hypertension Associated With Postoperative Endoscopic Treatment: Results of a New Approach

AIM

To propose a laparoscopic treatment for schistosomal portal hypertension.

METHODS

Ten patients with schistosomiasis and portal hypertension, with previous gastrointestinal hemorrhage from esophageal varices rupture, were evaluated. Patients were subjected to a laparoscopic procedure, with ligature of splenic artery and left gastric vein. Upper gastrointestinal endoscopy was performed on the 30th postoperative day, when esophageal varices diameter was measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.

RESULTS

There was no operative mortality. One patient had a postoperative splenic infarction that was conservatively treated. Mean hospitalization time was 5 days. During endoscopy 30 days after surgery, a decrease in variceal diameters was observed in 6 patients. During follow-up (mean 84 mo), after endoscopic therapy 8 patients had eradicated varices, but 4 presented with recurrence. Considering the late postoperative evaluation, all patients had a decrease in variceal diameters. A mean of 3.8 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence; one had a minor bleeding episode and the other had 2 episodes of bleeding varices requiring blood transfusion. In both patients, bleeding was controlled with endoscopic therapy. No late mortality was observed.

CONCLUSIONS

Laparoscopic ligature of the splenic artery and the left gastric vein is a promising and less-invasive method for the treatment of schistosomal portal hypertension.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension

AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension.

METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30^th postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.

RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.

CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.

Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension

BACKGROUND

The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding.

AIM

To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension.

METHODS

Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate.

RESULTS

The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%.

CONCLUSION

There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.

Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab's operation) for control of severe varices due to portal hypertension

BACKGROUND

Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension.

METHODS

Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group).

RESULTS

Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group.

CONCLUSIONS

The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.

Association between Micronutrients (Vitamin A, D, Iron) and Schistosome-Specific Cytokine Responses in Zimbabweans Exposed to Schistosoma haematobium

Micronutrients play an important role in the development of effective immune responses. This study characterised a populations exposed to schistosome infections in terms of the relationship between micronutrients and immune responses. Levels of retinol binding protein (RBP; vitamin A marker), vitamin D, ferritin and soluble transferrin receptor (sTfR), and C reactive protein (CRP) were related to levels of schistosome specific cytokines (IFN-γ, IL-4/5/10) in 40 Zimbabweans (7-54 years) exposed to Schistosoma haematobium infection. 67.2% of the participants were deficient in vitamin D. RBP levels were within normal ranges but declined with age. The two indicators of iron levels suggested that although levels of stored iron were within normal levels (normal ferritin levels), levels of functional iron (sTfR levels) were reduced in 28.6% of the population. Schistosome infection alone was not associated with levels of any of the micronutrients, but altered the relationship between parasite-specific IL-4 and IL-5 and levels of ferritin and sTfR.

Long-term results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in schistosomal portal hypertension

BACKGROUND

Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results.

METHODS

Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5 years of follow-up, were analyzed.

RESULTS

The mean follow-up was 116.4 months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed.

CONCLUSIONS

The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

Benefit of combination β-blocker and endoscopic treatment to prevent variceal rebleeding: A meta-analysis

AIM: To determine whether the association of β-blockers with endoscopic treatment is superior to endoscopic treatment alone for the secondary prophylaxis of oesophageal variceal bleeding.

METHODS: Randomised controlled trials comparing sclerotherapy (SCL) with SCL plus β-blockers (BB) or banding ligation (BL) with BL plus BB were identified. Main outcomes were overall and 6, 12 and 24 mo rebleeding rates, as well as overall and 6, 12 and 24 mo mortality. Two statistical methods were used: Yusuf-Peto, and Der Simonian and Laird. Inter-trial heterogeneity was systematically taken into account.

RESULTS: Seventeen randomised controlled trials were included, 14 with SCL and 3 with BL. Combination β-blocker and endoscopic treatment significantly reduced rebleeding rates at 6, 12 and 24 mo and overall [odds ratio (OR): 2.20, 95% confidence interval (CI): 1.69-2.85, P < 0.0001] compared to endoscopic treatment alone. Mortality at 24 mo was significantly lower for the combined treatment group (OR: 1.83, 95% CI: 1.16-2.90, P = 0.009), as well as overall mortality (OR: 1.43, 95% CI: 1.03-1.98, P = 0.03).

CONCLUSION: Combination therapy should thus be recommended as the first line treatment for secondary prophylaxis of oesophageal variceal bleeding.

Small-bowel lesions caused by portal hypertension of schistosomal origin: a capsule endoscopy pilot study

BACKGROUND

Schistosomiasis is a highly prevalent disease. It can evolve to its hepatosplenic form in up to 10% of the cases. The small-bowel lesions developed during the hepatosplenic stage of the disease have not been described in vivo.

OBJECTIVE

The aim of this study was to describe, for the first time, in a pilot study, the endoscopic aspects of the lesions in the small bowel of patients with portal hypertension due to schistosomiasis, using the PillCam SB, and to determine the usefulness of the method for the diagnosis of esophageal varices.

DESIGN

Case series.

SETTING

Tertiary-care medical center.

PATIENTS

Nine nonrandomized patients with hepatosplenic schistosomiasis and esophageal varices without previous GI bleeding were selected based on findings from the PillCam SB. Patients using medications that could alter the coagulation, with history of abdominal surgery, who were undergoing treatment of the portal hypertension other than beta-blocker, and with symptoms suggesting bowel obstruction were excluded. The findings were interpreted by a single endoscopist.

RESULTS

Capsule endoscopy was able to diagnose esophageal varices in all 9 patients. All of the patients presented angioectasias and venectasias in the small bowel. Small-bowel varices were present in 22.2% of the patients; edema and erosions were found in 66.7% and 88.9%, respectively. Lesions of so-called "scarred mucosa" were found in 55.5% of the patients.

LIMITATIONS

Small number of patients; case series.

CONCLUSION

The PillCam SB was effective, giving a significant contribution to the description of the esophageal varices and small-bowel lesions of the patients with portal hypertension caused by Schistosoma mansoni.

Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices

BACKGROUND

Bleeding from esophagogastric varices is the major cause of death in patients with portal hypertension. Although esophageal varices can be treated with endoscopic procedures, the treatment for gastric varices is still controversial. The aim of this study was to describe a surgical technique and our preliminary results of hand-assisted laparoscopic Hassab's procedure.

METHODS

Between February 2002 and May 2005, we performed 7 cases of gastric varices with this type of operation. The patients included 4 men and 3 women who ranged in age from 23 to 74 years (underlying liver disease: 5 case of liver cirrhosis, 1 case of polycystic disease, 1 case of extrahepatic portal vein obstruction). After splenctomy was performed, we devascularized the vessels of the upper stomach and the esophagus 5 cm away from the esophago-cardia junction.

RESULTS

The operative time ranged from 132 to 290 minutes. Intraoperative blood loss was estimated to be from 50 ml to 475 ml. The weight of removed spleen ranged from 110 g to 800 g. During the follow-up period, all gastric varices disappeared and no bleeding from varicose veins was observed. All patients had hypersplenism with thrombocytopenia before surgery (mean: 11.1+/-7.4x10(4)/ml), which was improved postoperatively (mean: 30.8+/-19.0x10(4)/ml). This data were statistically significant (P=0.033). One patient died of aspiration pneumonia related to postoperative pyloric stricture.

CONCLUSIONS

Although there is no agreement concerning the best treatment of gastric varices, the hand-assisted laparoscopic Hassab's operation is a safe, moderately invasive method, and its outcome appears to be equal to that of other open procedures.